Tips and Tricks of Avoiding and Management of Anastomotic Complications

1. Tips and Tricks of Avoiding and Management of Anastomotic Complications Feza H. Remzi, MD, FACS,FASCRS., FTSS (Hon) Chairman Department of Colorectal Surgery Professor of Surgery Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH

2. Introduction • Colorectal / anal • Ileal Pouch anal anastomosis • Ileocolic anastomosis • Small bowel to small bowel

5. Colorectal / Anal Anastomosis

21. Acute Management • Not diverted, • Take back for washout with diverting loop ileostomy and avoid taking down the colorectal anastomosis • Drain; I still prefer penrose drains • Diverted • If leak is proven with CT or GGE; EUA and transanal, anastomotic drainage through the defect • If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal • Prefer mushroom catheter • IV ATBS, and conservative management and control of sepsis and wait, wait, and wait

22. Longterm Management of Colorectal / Anal Anastomotic Leak • Wait 6 to 12 months • Periodic EUA, I & D of cavity, GGE • If it heals, proceed with ileostomy closure • If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure • Incomplete healing / closure of the defect • Ileostomy closure and explain the possibility of recurrence • Presacral sinus with a wide mouth/opening usually does better • Cavity that got epithelized with mucosa also does well

29. Turnbull- Cutait Pull Through

33. Turnbull Cutait

34. Ileal Pouch Anal Anastomosis

35. TPC and IPAA

44. Reach Issues

45. Difficulty in Reach